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By Torrey Creed, PhD Adjunct Faculty, Beck Institute

While a description of CBT for Autism Spectrum Disorders (ASD) would require a large volume (at least), let’s highlight several important areas to consider when working with people with an autism spectrum disorder (ASD). First, a word about what we do not do in CBT for ASD: we do not treat the ASD itself. CBT will not move someone to being neurotypical, nor should it. Instead, we focus on secondary issues that are related to the experience of life on the autism spectrum: depression, bullying, stress, anger, aggression, anxiety, social skills deficits, and limited social support.

People with ASD have unique cognitive and behavioral styles, which vary with the severity of their ASD symptoms. Therefore, as with any client, we creatively adapt and adjust CBT to meet the strengths and needs of the individual. People on the ASD spectrum are generally very concrete thinkers, so we need to modify standard CBT to be more experiential and concrete than usual. Individuals who are cognitively on the higher end of functioning may benefit from a mix of both cognitive and behavioral strategies, but when their functioning is more impaired, the therapist de-emphasizes cognitive techniques. The ideas described below may be a better fit for a higher-functioning client, but most can be made more concrete for someone whose cognitive style makes abstract thought even more challenging.

As with all CBT clients, we start with a cognitive conceptualization, identifying key cognitions and behaviors to target in treatment. Engagement and the therapeutic relationship are key with any client, but building these with clients with ASD may be even more essential, and also challenging. Therefore, from the beginning of treatment, we help clients explore their goals, passions, and values, then identify specific steps that CBT can help them make in service of that long term goal. Framing treatment about things the individual truly values can increase both engagement and the relationship. Aspects of the ASD or the sequelae from secondary issues (e.g. information from the case conceptualization) are framed as challenges to reaching the goals, and CBT then becomes a way to address those challenges in order to move toward the tailored goals.

A component of treatment often focuses on the “rules of the game” in social situations, which may be intuitive to others but are generally very hard for a person with ASD to penetrate. CBT helps them learn to better read social interactions and read others’ reactions and behavior more accurately so they can more easily monitor and adjust their own behavior and responses. We help people work toward self-acceptance and compensatory strategies to mitigate the impact of things that cannot be changed (like specific cognitive deficits). We also help them learn to recognize and modify unhelpful patterns of information processing which contribute to stress, anxiety, and depression. Our major focus, as in any CBT, remains on teaching cognitive and behavioral skills and strategies that will help the person move closer to his or her goals, as well as preventative strategies to decrease or prevent symptoms of comorbid mental health concerns, such as anxiety disorders and depression.

Common beliefs of people with ASD include “I must stay in control because there may be danger;” “If I try to fit in, I’ll fail;” “If I stay away from people, I won’t get hurt;” “I can’t understand what is going on in [my] world;” or “Everyone takes advantage of me.” They also have negative beliefs about themselves, “I’m flawed;” “I’m weird,” “I’m out of control;” “I’m incompetent;” or “I’m vulnerable.” These beliefs may pose serious challenges to reaching a person’s individualized goals, and often these beliefs can become self-fulfilling prophecies. Helping people to shift to more accurate and more helpful cognitions is a powerful tool in helping them realize their goals and potential.

When the client is a child with ASD, that child is usually the identified client; however, working with families is also essential. Families may struggle with ASD-related issues, including a child’s obsessive interests, angry outbursts, poor self-care, repetitive rituals, and odd behavior. Parents may also experience frustration (with the child, or with others’ reactions to the child), and siblings may have strong reactions to their own experiences of being in a family with a child with ASD. Helping family members to identify ways in which their patterns of thinking, feeling, or behaving may be more or less helpful (or accurate) can help shift the dynamic of the family in a positive direction.

There is much more to learn about CBT with individuals with ASD. The work can be challenging but is also highly creative-and rewarding, as we see them and their families reaching their own meaningful goals.

https://www.beckinstitute.org/wp-content/uploads/2016/08/beck-cbt-logo-white.png00Andrew Bartoshhttps://www.beckinstitute.org/wp-content/uploads/2016/08/beck-cbt-logo-white.pngAndrew Bartosh2015-04-28 08:24:392016-08-16 15:56:32An Introduction to CBT for people with an Autism Spectrum Disorder

Autism Spectrum Disorders (ASD) is an umbrella term representing a range of persistent cognitive deficits and impairments in communication and social interaction, often diagnosed by age two, and includes autistic disorder, Asperger’s syndrome, and pervasive developmental disorders. Children with ASD are at an elevated risk for developing anxiety disorders, which can become highly debilitating across environmental contexts (home, school, and social contexts). The results of previous research (case studies, small group studies, and randomized clinical trials) have provided evidence and support for the efficacy of modified CBT for youth with ASD and anxiety.

In a 2012 study published in Autism Research and Treatment, researchers developed a modified version of a CBT intervention (“Facing Your Fears”) for adolescents with ASD, titled “Facing Your Fears: Group Therapy for Managing Anxiety in Children with High Functioning ASD” (FYF-A). They then assessed the feasibility and acceptability of the FYF-A intervention program.

Participants included 24 adolescents and their families, age 13-18, with ASD and anxiety. They attended 14, 90-minute sessions, plus 1 booster session, which included large group activities with teens and parents, small-group activities with teens and parents alone, and dyadic work with parent and teen pairs. The program focused on core CBT components (including an introduction to anxiety symptoms and implementation of CBT strategies) and several modifications for teens with ASD. These modifications included: (1) a social skills module to address areas of social challenge; (2) parent-teen dyadic work focused on achieving a mutual understanding and shared goals; (3) the use of technology to both monitor symptoms of anxiety and remind participants to utilize CBT strategies; and (4) a parent curriculum.

At post-treatment, participants showed significant reductions in anxiety severity and intrusiveness. These reductions were maintained at the 3-month follow up. Further, nearly half of the participants met criteria for a positive treatment response on primary diagnosis following the intervention. These finding are encouraging, as they add further evidence that modified CBT for adolescents with ASD is effective in decreasing anxiety symptoms among this group.

A recent open trial conducted by researchers at the University of South Florida tested the effect of family-based cognitive-behavioral therapy (CBT) on children and adolescents with Obsessive-Compulsive Disorder (OCD). The participants were 30 youth (7-19 years old), half boys and half girls, who were partial or nonresponders to two or more medication trials. Each patient received 14 sessions of intensive family-based CBT.

At post-treatment and 3-month follow-up, 80% of participants had improved. Symptom severity was reduced by 54%. Over 50% were classified as being in remission at the end of treatment, and at the 3-month follow-up. While there was no notable difference in self-reported anxiety, researchers observed significant reductions in OCD-related impairment, depressive symptoms, behavioral problems, and family accommodation.